Bryan Mehlhaff1, John Azzolina2, Wanda Wilt3, Sherri Moroni3, Keely Clary2, Shailendra Sharma2
1Oregon Urology Institute,2PPS Analytics, 3UroGPO, 2,3Specialty Networks, LLC Companies
PPS Analytics works with our industry partners to engage in large scale research projects within the urology. Retrospective and prospective research projects are undertaken to understand current treatment patterns and to explore new avenues for treating patients across the spectrum of disorders in the urology space.
Guidelines for clinically localized prostate cancer recommend radical prostatectomy or radiotherapy plus androgen deprivation therapy (ADT) as the standard of care for patients with intermediate to high-risk localized prostate cancer.1 Luteinizing hormone-releasing hormone (LHRH) therapy is a medical castration form of ADT used to chemically reduce the levels of androgens in the male body.2 While LHRH therapy reduces serum testosterone to castrate levels, it can also cause secondary complications such as decreased bone mineral density (BMD) leading to osteopenia, osteoporosis, and skeletal bone fractures associated with higher risk mortality.3,4,5,6
Dual-energy X-ray Absorptiometry (DEXA) scans can be used to measure BMD in men to determine if there are any abnormalities that require additional treatment such as bone anti resorptive therapy and/or the supplementation of calcium and vitamin D. While recommended by the National Comprehensive Cancer Network (NCCN), there are currently no requirements for screening prostate cancer patients on LHRH therapy for baseline BMD.7,8 Furthermore, complementary therapies exist to prevent the loss of bone density, however, it is unclear how often LHRH patients are treated accordingly.
We identified 67,400 male patients, representing 9 Medicare Regions, who met inclusion criteria. Patients were 79.4 9.8 years old on average (median: 80, range: 50 104). Over the course of the study period (1995 2019), 18.9% (n = 12,768) of patients expired. Patients predominately self identified as white (67.0%), or black (15.9%). On average, patients remained on continuous LHRH therapy for just over two years (mean: 25.3 17.3 months, median: 19 months, range: 12 - 227 months). Of the 67,400 patients included in the study, 14,811 (22.0%) have ever received a DEXA scan to measure BMD. The proportion of patients undergoing a DEXA scan varied significantly by Medicare Region (p < 0.001)
Proportion of patients receiving a supplemental bone health therapy also varied by Medicare Region. (p < 0.001) (Chart 2). Overall, 52.1% of patients (n = 35,135) were on supplemental bone health therapy, with the most common type being Vitamin D (29.7%) followed by Calcium (25.8%) (Chart 3).
Currently, DEXA scan completion rates on prostate cancer patients undergoing continuous LHRH therapy differ by Medicare Region, with a completion rate ranging from 13.0% in Region 7 to 45.1% in Region 8. Similarly, supplemental bone health therapy practices are inconsistent and vary across region.
Further research is needed to look at the proportion of LHRH patients undergoing a baseline DEXA, while excluding those with known decreased BMD, to identify barriers and trends within region and/or demographics. Such findings will help identify target areas for outreach and influence recommendations for the clinical pathway and care of prostate cancer patients undergoing continuous LHRH therapy.
1 Sanda MG, et al. Clinically Localized Prostate Cancer: AUA/ASTRO/SUO Guideline (2017).
2 The American Cancer Society medical and editorial content team. Hormone Therapy for Prostate Cancer.
3 Michaelson MD, et al. Randomized Controlled Trial of Annual Zoledronic Acid to Prevent Gonadotropin Releasing Hormone Agonist Induced Bone Loss in Men with Prostate Cancer.
4 Shahinian VB, et al. Risk of fracture after androgen deprivation for prostate cancer.
5 Oefelein MG, et al. Skeletal fractures negatively correlate with overall survival in men with prostate cancer.
6 Shao YH, et al. Fracture after androgen deprivation therapy among men with a high baseline risk of skeletal complications.
7 National Comprehensive Cancer Network (NCCN). NCCN Guidelines Version 4.2019 Prostate Cancer.
8 National Comprehensive Cancer Network (NCCN). NCCN Guidelines for Patients: Prostate Cancer, 2018. Chapter 6: Treatment Monitoring, pages 63 64.
9 Yee EFT, White RE, Murata GH, Handanos C, Hoffman R. Osteoporosis Management in Prostate Cancer Patients Treated with Androgen Deprivation Therapy.